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Processing referrals for HMOs and Medicare as direct pay physician

  • 1.  Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-08-2019 13:42
    Starting a cash only practice, so I have a couple of basic questions for anyone else not contracting with insurance/DPC practice model folks.  Ideally, I will mostly see uninsured patients, those with Christian Health Share plans, and those with PPO plans, since these can pay me cash and possibly submit their own claims.  That all seems clear.
    People with HMO plans can obviously see me but not get reimbursed (since I am not in network).  This probably isn't that big of a deal for them most of the time, since some of these deductibles are so high that they are unlikely to meet their deductible anyway, so they might as well pay cash to see whoever they want for their PCP.  The downside is that I don't think that I can do any referrals to specialists for them, if I'm not mistaken.  Does this mean that if they do need a referral, I will have to have them see an in-network PCP in their HMO to get the referral?
    I plan to opt out of Medicare once I am done moonlighting.  I basically have the same question as above for this.  Who processes the referrals to specialists?  How do you DPC folks do this?
    Finally, I'm assuming that I can't charge Medicaid patients cash, correct (i.e. that I can't see them in a cash-pay practice)?  I am in Arizona.

    Thanks everyone. You have been such a huge help to me, especially with the "start-up checklists" that have been posted on here.


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    Bradley
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  • 2.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 03:26
    In my experience I can not see patients from HMO'S that I am not contracted with. Most of the time the insurances will assign the patients to you. You can not charge cash to patients that have HMO if you are not in network. I think the referrals would  be the least of my concerns. We can see in the political arena that Medicare for all is being rolled out as we speak that is the reason why all the private insurances have now Medicare " Disadvantage" plans  ( as I call them) If you opt out of Medicare you probably will not be able to see a lot of patients. My recommendation continue moonlighting until your practice is allowing you to have the lifestyle that you want. This is my 4th year , just breaking  even without a normal Family Physician salary.  I don't  believe in luck. So I will send blessings your way.





  • 3.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-10-2019 03:20
    I am not contracted with Medicaid, in Florida, I can not see Medicaid patients. If I see a Medicaid patient for any reason that I might decide. I can not charge the visit. It is illegal. Medicaid population are usually low income folks that need the assistance of the state. If they can pay for their visit, then they are committing fraud!!!





  • 4.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-10-2019 03:53
      |   view attached

    I don't believe that is correct – here is CMS opinion paper on the requirement for states to have "any willing provider" options for access.

     




    Attachment(s)

    pdf
    smd16005.pdf   181K 1 version


  • 5.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-13-2019 06:34
    This is very interesting - I only read the first pages of the document - - I think one issue is that many states (I know Iowa did) now have Medicaid as "managed care" and so unfortunately, Medicaid beneficiaries then lose their "any willing provider" access. . . . 

    It is at times like this I wish the ABFM/AAFP/IMP etc. would have in-house counsel at our (the docs') disposal.  Now THAT would be a benefit that would offer us more power in the medical landscape.  

    Deborah





  • 6.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 06:18

    Bradley,

    We are an opt out Medicare practice.  It is my understanding that those covered by certain 'advantage' plans operate essentially as the old fashioned HMO in that a referral from a contracted PCP is required.  We have about 150 or so Medicare folks and only one of them, to my knowledge, has this sort of plan. So I think it depends on how much penetration these plans have in your market. Same with commercial insurers who require a 'mother may I' from the PCP to see a specialists or have testing paid under their insurance.

     

    Jim Bloomer






  • 7.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 06:47

    Good morning Dr. Bradley,

     

    Congrats on starting your cash practice – we've been in a direct care practice for 9.5 years and have helped over 700 docs convert to the model.

     

    It's a fantastic model, especially for the uninsured b/c you can do a membership that offers unlimited visits, no copays, free procedures and wholesale medicines and labs for up to 95% savings

     

    Here's a link to our wholesale pricing on meds/labs/imaging as an reference point: http://bit.ly/2JoVyJi

     

    In our experience the patients don't/won't submit their own claims to typical insurance carriers.  The Christian co-ops may give discounts back to families that are working with DPC – the coops are finding out that they save $$$ when the families are using DPC.

     

    Referrals generally work 1 of 2 ways depending on the type of system (hmo vs ppo etc).  either the system allows any referral, or they require all referrals to go through an in network provider first.  The first is easy and the second is a hassle for sure, but really just 1 extra step and we blame it on their insurance J.  In our area, both hospital chains take all insurances so it ends up be a non issue when referring.   But with wholesale meds/labs/imaging/pathology, there's a lot you can do without going through the insurance system.

     

    Also specialty consult services like rubiconmd.com make it easy to get doc-to-doc curbsides quickly (flat monthly rate for the service, unlimited consults)

     

    If you're opted-IN to medicare, then you can't charge cash/memberships.

     

    You CAN moonlight as an opted-OUT  physician - https://www.dpcfrontier.com/opted-out-moonlighting

     

    If/when you opt-OUT, then you can charge medicare patients cash/memberships.

     

    Let me know if there's anything else I can do to help.

     

    Thanks,

    Josh

    C 316.734.8096

    drjosh@atlas.md






  • 8.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 16:35
    My understanding from several years ago (I might have outdated info) was that in WI/IA a cash based practice would have to accept Medicaid from patients with Medicaid.  In fact, in Iowa there was a case about a doctor, (possibly running a "pill mill"), but what got him in legal trouble was that he was charging patients $100 cash for the urine drug screen (best practice) and visit (which seemed a reasonable cost!), when they were on Medicaid.  My understanding is that you would need to establish that the patient was NOT on Medicaid before seeing them.  There is the question of what to do if they say they are not on Medicaid, are willing to pay cash for services, but in fact ARE on medicaid - - and I would research or ask a lawyer about that one.  







  • 9.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 18:23
    I see primarily Medicaid. From my understanding there is a hefty fee if a provider knowingly sees someone with Medicaid for a cash visit. In Colorado, Medicaid will also not cover prescriptions written by a out of network provider.

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    Marie Amina Aryan, NP-C
    FNP
    Lakewood Family Health Clinic
    303-578-8191
    Lakewood, Colorado
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  • 10.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 18:42

    Hello Marie,

     

    Colorado and Kentucky are the only states that do not allow Medicaid patients to use doctors outside of the Medicaid system -- https://www.dpcfrontier.com/medicaid

     






  • 11.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 18:43

    Hi Dr. Lathrop,

     

    The only states that don't allow Medicaid patients to privately contract with doctors outside of Medicaid are Co and KY - https://www.dpcfrontier.com/medicaid

     

     

     






  • 12.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 18:21
    First, congratulations on making the jump! I would never go back. Referrals tend to be a very case by case basis. Some of the insurers are very strict about only accepting referrals from an in network physician, others seem not to care very much. My strategy has generally been to not advertise the fact that I am not in their network. I would say, however, that referrals are one of the more challenging parts of being a DPC doc.

    I also estimate that my need to refer has fallen by about 80% since going to DPC; look into a RubiconMD subscription.

    In terms of Medicaid, there is nothing in California that I am aware of that prevents direct contracting with a Medicaid patient. While there may be state specific rules, I doubt it. Having patients sign a Medicare opt out is important though.

    Good luck. Please reach out with any more questions.

    Justin Altschuler, MD
    sequoiamd.com




  • 13.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-09-2019 18:40

    Hi Dr. Justin – I agree! Referrals go way down when you have time to spend with patients and affordable resources like wholesale meds and las.

     

    You're also correct, in California you don't have to take Medicaid and Medicaid patients are allowed to privately contract with other doctors.

     

    Josh






  • 14.  RE: Processing referrals for HMOs and Medicare as direct pay physician

    Posted 07-10-2019 07:53
    Bradley

    Without telling us where you are,  you see you get all kinds of answers
     Physicians  should recall  MEDICAID IS STATE SPECIFIC   so  answers about what  THEY do may not help YOU
    Medicaid is funded partly by feds and partly by the state and the state administer it though follows general Fed rules but can ask for waivers   Hence  in some states If a patietn has medicare  they can have medicaid also that will pay their 20% etc   THAT is real nice for the doc  who does  nothave to collect the 20%  from a patient or even a secondary That is,in some states   so called dual eligibility is allowed  You want resources  in your state   I f you do not belong to your state medical association do it  now

     medicaid  cash pay patient are  probably forbidden anywhere ,sounds like.  Of course if you did not know and they come in  nothing will happen( but those are usually the drug seekers Most of them  really do not have $)

     HMOS vary by state also Where i live and be careful this could be true where you are  there are TWO kinds of referrals ONE is that  HERE NO specialist will EVER see a patient unless I refer as there are FEW and they are erecting barriers to  keep out the hordes(they will not even make me an  appointment on the phone til I submit my paperwork for evaluation!!)  In most places however there are plenty  and they are hungry KNOW  your community.  Take time to  get in good with practice managers at  ortho and neuro and pulm and cards. TWO  is that one we are talking about here, and involves $$. If patient  has HMO and needs to see another doc that doc must be in the network and the patient must have a referral . If you are operating under the arguable assumption that oh patients have such high deductibles that they will pay AGAIN and go see the specialist and pay cash , then  who cares .Know your community. And know what  YOU are willing ot explain over and over.( choose your poison )People on this list serv  spew out posts like they know   At some point,, you see, patients want that cost to go against their deductible
     You cannot refer an hmo patient ,I suspect anywhere,(as that is the point of HMOs) if you  a re not in network AND expect it to  be paid for. YOU CAN DO ANYTHING you want, realizing  you put patients in a certain financial position
    Bottom line Find someone in your state to help you
     Test your community waters carefully  Do not listen to all the  do this  don't this stoires here becasue YOUR town is what matters

     Regions/attitudes vary  Test it carefully
    It is often  better  in building a practice to drop insurances later rather than  take them on later.

     now, if you are not in an HMO and the patient gets admitted or uses the er or hopsitla lab  no referral is needed-usually --it COULD be for the er.
     If you expect patient to understand their own insurance  give up and go home :)

     Medicare now is the easiest to deal with despite  being its own  PIA  NO referrals no prior auths UNLESS it is a meidcare advantage plan-whihc cna have ridiculous  prior auths .
     NO copays

    Come  to MAine  we need you HAve some lovely thriving small practices here
    But most things in primary care  suck:)My real advice is to  do something else/Can  you drive an 18 wheeler?


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    Jean Antonucci
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